HA

Cards (399)

  • General Survey
    First part of the Physical Examination that begins the moment the nurse meets the client
  • General Survey

    • Requires the nurse to use all of her observational skills (inspection) while interviewing and interacting with the client
    • These observations will lead to clues about the health status of the client
    • The outcome of the general survey provides the nurse with an overall impression of the client's whole being
  • Physical Assessment
    Systematic, comprehensive, continuous collection, validation, and communication of client's data using a variety of methods
  • Assessing Appearance and Mental Status
    1. Explain procedure to the patient
    2. Do handwashing
    3. Provide privacy
    4. Observe body built, height, and weight
  • Marfan Syndrome
    • Disorder of connective tissues manifested by changes in the skeleton, eyes, and cardiovascular system
    • Inherited gene defects in fibrillin (a glycoprotein) result in formation of abnormal elastic fibers
  • Gigantism
    Enlarged soft tissue and late closure of the growth plates
  • Dwarfism
    • Essentially a person with short stature
    • Little People of America (LPA) – 4'10" or under
    • May be caused by: Gonadal dysgenesis (XO → Turner syndrome), Bone and metabolic diseases, No known cause (constitutional delayed growth), Chronic abuse and neglect (independent of nutrition), Genetic mutations (achondroplasia)
  • Proportionate Dwarfism
    The same size all over (e.g. hypothyroidism)
  • Disproportionate Dwarfism
    May have some average-size parts of the body
  • Achondroplasia
    • Most common form of dwarfism
    • Happens when growth plate chondrocytes are inhibited from functioning and proliferating (leads to suppression of epiphyseal plates)
    • Epiphyseal plates will close 12-14 years old for females and 16-18 for males
    • This stunts growth (but may have average-size portions of their bodies → torso)
  • Sthenic
    • Normal average body type
    • Average height, well-developed musculature, wide shoulders, flat abdomen, and oval face
    • Muscular, thick-set individual, with broad chest and high diaphragm
    • Stomach tends to lie transversely
    • Gallbladder is high in the abdomen (away from midline)
    • Transverse colon also high
  • Hypersthenic
    • Short, stocky, may be obese, broader chest, thicker abdominal wall, rectangular-shaped face
    • Very muscular, thick-set individual (higher weight class)
    • Broad chest
    • High diaphragm
    • Stomach tends to lie transversely
    • Gallbladder is horizontal high in the abdomen (away from midline)
    • Transverse colon also high
  • Asthenic
    • Long, thin-chested lean individual (marked thinness)
    • Lower positioned organs (diaphragm, stomach, gallbladder, and transverse colon)
    • Stomach and transverse colon descend into pelvis (during erect position)
    • Exaggeration of the hyposthenic type
  • Hyposthenic
    • Tall, willowy, poorly developed musculature, long, flat chest, abdomen may sag, long neck, triangular face
    • Similar to asthenic but features mentioned are not as marked
  • Cachectic (Cachexia)

    • Profound and marked malnutrition
    • Wasting (muscle wasting – primary source of energy is glucose → if patient doesn't eat → muscle loss)
    • Ill health (chronic conditions such as cancer, CRF, HIV, MS)
  • Debilitated
    Weak, feeble, lack of strength (with weakness and loss of energy)
  • Failure to Thrive
    • Physical and developmental delay or retardation in infants and children
    • Due to malnutrition
    • Seen in children with illness but more in those with psychosocial or maternal deprivation
  • Endomorph
    Stocky build, with prominent abdomen
  • Ectomorph
    Physiological type that is tall with long and lean limbs
  • Mesomorph
    Husky and muscular body
  • Body Mass Index (BMI)
    • Ratio of your weight and height
    • Weight in kilograms divided by height in meters squared
    • Weight in pounds multiplied to 700, divided by height in inches, divided again by height in inches
  • Waist Circumference
    • Male: ≤ 102 cm (40 in)
    • Female: ≤ 88 cm (35 in)
    • Abnormal: anything beyond the measurements
  • Obesity
    Can be caused by: Poor diet (high in fat and calories), Sedentary lifestyle, Not enough sleep, Genetics, Increasing age, Pregnancy
  • Gynoid/Gynecoid Obesity
    • Fats are located on the hips and thighs
    • Peripheral type of obesity
  • Android Obesity
    • Fats are located mainly on the waist
    • Central type of obesity
    • Increases risk for certain diseases (diabetes mellitus II, high cholesterol and triglycerides, hypertension, and heart disease)
    • Thrombus or emboli → inside small blood vessels → occlusion or blockage of blood vessel → reduces blood flow and oxygen to the brain → Ischemic CVA (no oxygen supply = irreversible brain damage/brain death can happen after 2 minutes)
  • Cushing Syndrome
    • Due to excess cortisol in the body (from medications or pituitary gland tumor)
    • Truncal fat (abdominal fat)
    • Thin limbs (relatively)
    • Cardiac hypertrophy (abnormal enlargement of heart muscle)
    • Abdominal striae (stretch marks)
    • Amenorrhea (doesn't have menstrual period)
  • Unplanned weight loss
    Can be caused by: Cancer, Diabetes mellitus, Hyperthyroidism, Depression, Diuresis
  • Posture and Gait Assessment
    1. Let patient stand against the wall (with shoulders lying flat)
    2. Let patient sit on a chair with backrest
    3. Let him/her walk towards you
    4. Be aware: walking has 8 phases (motion of walking)
  • Normal Posture and Gait
    • Evenly distributed weight
    • Able to stand on heels and toes
    • Toes pointed straight ahead (equal on both sides)
    • Posture erect, movements coordinated and rhythmic, arms swing in opposition, stride length is appropriate
  • Abnormal Posture and Gait
    • Limping/discomfort (Antalgic/Limping gait)
    • Shuffling (common in Parkinson's disease; in elderly)
    • Wide/broad base gait (can have structural deformities/ fracture in the hip)
    • Fear of falling (Psychogenic)
    • Loss of balance (Drunkenness)
    • Movement disorder (Ataxic Gait)
  • Scoliosis
    • "S" formation
    • Lateral curvature in the normally straight vertical line of the spine
  • Lordosis
    • Excessive inward curve of the spine
    • Exaggerated lumbar concavity
  • Kyphosis (Hunchback)

    • Increased forward curvature of the spine
    • Causes hunching of the back
  • COPD Posture
    • Lean forward
    • Brace selves with arms
    • Tripod position
  • Depression Posture

    • Slumped position
    • When patient is withdrawn or isolated
  • Tense/Anxious Posture
    • Shoulders elevated
    • Stiff (especially in the neck)
    • Nail biting
    • Facial expression
  • Breath Odors
    • Alcohol breath
    • Halitosis (bad breath caused by food particles, and bacteria, etc.)
    • Acetone breath (diabetes mellitus - sweet and fruity breath indicates diabetes ketoacidosis)
  • Body Odors
    • Presence = bromhidrosis
    • Asians and Native Americans have fewer sweat glands (less obvious body odor than Caucasians and Black Africans)
  • Signs of Distress in Posture or Facial Expression
    • Observe at rest (during conversation)
    • Note degree of eye contact – natural, sustained, and unblinking/averted
    • Smiles and frowns appropriately
    • Immobile face/expressionless
    • Flat/sad with poor eye contact –depression
    • Decreased eye contact – anxiety/fear
    • Drooping or gross asymmetry in neurologic disorders/injuries: Bell's palsy, Cerebrovascular accident
    • Stare of hyperthyroidism (eyelid retraction, exophthalmos – protruding of the eyes)
  • Poor Nutritional Status
    • Listlessness/apathy
    • Poor muscle tone
    • Hair: thin/sparse
    • Cheilosis (fissure at mouth angles)
    • Glossitis (inflammation of the tongue)
    • Acute/chronically ill
    • Frail/feeble